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Thematic brief Nutrition and : Integrated approach for

effective case management Pixabay from Igor Ovsyannykov by Photography

Preventable infectious such as , and Key messages malaria account for one third of all under-five deaths. Globally, nearly half of all deaths among children under five are attributable to (Caulfield 2004). In Asia Pacific, 351 million people are and nutrition are closely related still undernourished, and the COVID-19 pandemic will only exacerbate due to effects on metabolism and immunity. this figure. UNICEF estimates an additional 6-7 million children under 5 Socio-economic conditions and limited globally will suffer from acute malnutrition as a result (UNICEF 2020). system capacities also impact risks of both This means more people – especially children – will have weakened rates and poor nutrition outcomes. immunity and be at greater risk for infection including from malaria (FAO et al 2021). While the intersection between nutrition and malaria remains under-researched, particularly in Asia Pacific, evidence shows Malaria and malnutrition coexist in a vicious that children and pregnant women are the most affected by poor cycle: as malnutrition and key deficiencies nutrition and are at the highest risk of adverse effects from malaria can increase the risks of developing severe infection. Despite considerable progress to improve access to services malaria and lead to increased morbidity for all, malaria and malnutrition remain two of the leading causes of and mortality from infectious diseases. death in children under-5 years of age, particularly in sub-Saharan Infection with malaria can push children and Africa (WHO, 2019). Malaria (symptomatic or asymptomatic infections) pregnant women into a malnourished state. is also one of the leading contributors to anaemia in children under 5 and pregnant women in sub-Saharan Africa (WHO, World Malaria Report, 2019) (UNICEF, 2020). Maternal anaemia puts the mother at Low- and middle-income countries (LMICs), increased risk of maternal mortality before and after (WMR where resources to support health systems 2019). The fetus and child born to a mother with maternal anaemia and access to health are often limited, and/or infection with malaria is at risk of being born preterm and/ bear the majority of the burden of malaria, or with a low weight at birth – which can lead to stunted growth and malnutrition and anaemia. Integration of cognitive development issues (WHO, 2017). Populations affected nutrition activities with malaria services by malaria, anaemia and malnutrition overlap and for this reason an should be considered for effective case integrated response that supports universal health coverage for all is management, especially in the vulnerable recommended to achieve the sustainable development goal of ending groups. Malaria workers can play a vital role in all forms of malnutrition and malaria by 2030 (United Nations, 2015). the delivery of malaria and nutrition services. Malaria, Malnutrition and Anaemia:

Malaria, anaemia and stunting Malaria and anaemia Malaria and stunting Map showing shared burden of Malaria, Anaemia and Malnutrition (Global Nutrition Report, 2020) (WHO, 2019)

Malnutrition and malaria: Nutrition related factors such as lack Anaemia and malaria: Anaemia is a condition in which you lack of calories and deficiencies in and other enough healthy red blood cells to carry adequate oxygen to are responsible for a substantial proportion of malaria morbidity your body’s tissues. It can be caused by nutritional deficiencies and mortality (Caulfield, 2004) (Sakwe, 2019). The cycle of in and folate, infectious diseases including malaria, HIV or malnutrition depends on a range of factors from weight of , or by genetic disorders (Tolentino, child at birth, maternal nutrition, gestation at birth, mother’s 2007). The risks from anaemia during such as still- age, feeding practices, recurrent illness and (WHO, birth, miscarriage and low-birthweight are high (Unger, 2016). Malnutrition). Nutrition received during fetal development can underpin a child’s future well- or ill-health (WHO, 2019). Malaria increases the risk of poor maternal and new-born outcomes including maternal anaemia, , Children under five are particularly vulnerable to both malaria spontaneous abortion, stillbirth, prematurity, low birth weight, and malnutrition and malaria can be more severe in children and new-born and death (WHO, Malaria in Pregnant that are malnourished. Evidence points out that malnutrition Women, 2017). Evidence shows that low birthweight can have increases susceptibility to malaria and that undernutrition is adverse impacts throughout the lifecycle of the individual. an important risk factor for the progression to severe malaria, especially in children (Sakwe 2019). Socio-economic co- Malaria accounts for an estimated 3–15% of anaemia and 25% of risk factors for children under five in LMICs for malaria and severe anaemia in pregnant women in malaria endemic countries malnutrition include lack of financing, poor housing, lack of (Steketee RW, 2001). For this reason, it is recommended that access to education (for both themselves and their mother) pregnant women with severe anaemia in malaria endemic areas or employment status of the parents (Sakwe, 2019). are treated presumptively with an effective antimalarial drug.

Solution Integrating approaches to address the co-morbidities of malnutrition, anaemia, malaria and other infectious diseases could have positive benefits to maternal and child health. This warrants more synergistic investments across programs in support of better integrated surveillance systems. Bangladesh for examples uses eIMCI as a web-based management system for the Integrated Management of Childhood Illness (IMCI).

Nutrition and Malaria: Integrated approach for effective case management · 02 “Integrated programmatic interventions” approach: The integration of maternal and child services with malaria prevention and treatment of preventable causes of child deaths through expanding access to services and treatments and improving quality of and demand for these health services. The primary diseases of poverty like malaria, but also and malnutrition impact the most vulnerable first. This suggests integrated programmatic interventions for effective case management of both malaria and malnutrition in vulnerable populations, in particular to protect pregnant women and children. Similarly, for pregnant women, the integration of infectious control services with antenatal care can result in better compliance and positive outcomes for both the pregnant women and unborn child. Photography by DUKE NG from Pixabay DUKE NG from by Photography

Focus On

A study was conducted in Northern Nigeria to assess whether integrating SMC (Seasonal Malaria Chemoprevention) with Plumpy’doz™, a lipid-based nutritient supplement (LNS), has an impact on nutrition or malaria outcomes. It was found that among those who had taken SMC and LNS in the past 30 days, the prevalence of clinical malaria were 61% lower than among those who received SMC only. It also provided evidence of an enhanced protective effect of adding LNS to SMC against clinical malaria (Ward, 2019).

Malaria Consortium, funded by Comic Relief, implemented a project to expand rural access to community-led services and address malaria and common childhood illnesses among under-5 children in 6 townships of Sagaing Region, Myanmar over the period of 2017-19. The project demonstrated that iCCM closes service gaps for malaria and other childhood illnesses and is a widely accepted approach. Malaria volunteers were able to conduct growth monitoring and promotion for under-5 children and facilitate community referrals for malnutrition cases who needed care. The evidence from this project is helping to facilitate the policy shift for the Ministry of Health and Sports’ adoption of new Community-based Health Workers Policy.

Donor organizations and development banks have a role to play in supporting an integrated approach to improving health and nutrition outcomes. With the aim of achieving universal health coverage in Lao PDR by 2025, a co-financing investment between the Global Fund, the World Bank and the Government of Lao PDR is dedicated to improving the quality and coverage of health and nutrition services by providing funds to health centers and departments using results-based instruments. The Health and Nutrition Services Access Project (HANSA) will help to tackle childhood stunting by increased access to and use of nutrition interventions. This will reduce co-morbidities among children of infectious diseases including malaria, Tuberculosis and HIV-AIDS (The World Bank, 2020).

Nutrition and Malaria: Integrated approach for effective case management · 03 Recommendations:

• Integration of malnutrition and anaemia interventions with malaria programs should be considered as part of universal health coverage. This also means strengthening equitable coverage of antenatal-care to deliver proven malaria prevention and treatment strategies. An integrated community case management for malaria, pneumonia and diarrhea and severe acute malnutrition can bridge gaps in clinical care in hard-to-reach communities.

• Additional research is needed to understand the immediate interaction of malaria, anaemia and malnutrition in different malaria endemic settings to better target integrated interventions.

• Integrated surveillance systems are required to produce a unified set of indicators to facilitate reporting, analysis and use of data for decision making. This will help to design effective integrated interventions.

• To support the integration of interventions, behaviour change communication and community dialogues that cohesively address more than one health issue and their interaction with each other, in this case malaria and nutritional health, can have exponentially beneficial effects for both child and maternal health.

• Lack of financial support remains a significant obstacle to service integration. It is important to consider ‘horizontal integration’ of financial and human resources when implementing integrated services for malaria and maternal and child health.

References i. Caulfield, L. E. (2004). Undernutrition as an Underlying Cause of xi. UNICEF (November 2020) press release Malaria Morbidity and Mortality in Children Less Than Five Years xii. UNICEF (2020) Averting a lost COVID generation https://www.unicef.org/ Old. American Journal of Tropical Medicine and Hygiene. reports/averting-lost-generation-covid19-world-childrens-day-2020-brief ii. FAO, UNICEF, WFP and WHO. 2021. Asia and the Pacific Regional xiii. United Nations. (2015). Retrieved from Sustainable Development Goals: Overview of Food Security and Nutrition 2020: Maternal and child https://sustainabledevelopment.un.org/sdgs. diets at the heart of improving nutrition. Bangkok, FAO. xiv. Ward, A. (2019). Seasonal malaria chemoprevention packaged with malnutrition prevention iii. Development Initiatives. (2020). Global Nutrition Report: in northern Nigeria: A pragmatic trial (SMAMP study) with nested case-control. PLOS ONE. Action on equity to end malnutrition. Bristol, UK xv. WHO. (2011). Hemoglobin concentrations for the diagnosis of anaemia iv. Leo Wattana, W. (2008). Defective erythropoietin production and and assessment of severity. WHO. xv. reticulocyte response in acute falciparum malaria-associated . Southeast Asian J Trop Med , 581-8. xvi. WHO. (25 May, 2017). Retrieved from https://www.who.int/ malaria/areas/high_risk_groups/pregnancy/en/ v. Stone-Jimenez, Maryanne, Bisola Ojikutu, Mulamba Diese, and Cassandra Blazer. 2011. Technical Brief: Integrating Prevention of Mother-to-Child Transmission of HIV xvii. WHO. (25 May, 2017). Malaria in Pregnant Women. Retrieved from World Health Interventions with Maternal, Newborn, and Child Health Services. Arlington, VA: USAID’s xviii. Organisation: https://www.who.int/malaria/areas/high_risk_groups/pregnancy/en/. AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. xix. WHO. (19 September, 2019). Retrieved from https://www.who.int/ vi. Nimpagaritse, M. (2019). Addressing malnutrition among children in routine news-room/fact-sheets/detail/children-reducing-mortality care: how is the Integrated Management of Childhood Illnesses strategy xx. WHO. (2019). World Malaria Report. Geneva: WHO. implemented at health center level in Burundi? BMC Nutrition xxi. WHO. (1 April, 2020). Malnutrition. Retrieved from World Health Organisation: vii. Sakwe, N. (2019). Relationship between malaria, anaemia, nutritional and socio-economic status amongst under-ten children, in the North xxii. https://www.who.int/news-room/fact-sheets/detail/malnutrition Region of Cameroon: A cross-sectional assessment. PLOS ONE. xxiii. WHO. (n.d.). Aneamia . Retrieved from World Health Organisation: https://www.who.int/health-topics/anaemia#tab=tab_1 viii. Steketee RW, N. B. (2001). The burden of malaria in pregnancy in malaria-endemic areas. The American journal of tropical medicine and hygiene, 28-35. xxiv. WHO. (n.d.). Malnutrition. Retrieved from World Health Organisation: ix. Tolentino, K. (2007). An update on anemia in less developed xxv. https://www.who.int/health-topics/malnutrition#tab=tab_1 countries. Am J Trop Med Hyg, 44-51. xxvi. Young, N. (2018). Integrated point-of-care testing (POCT) of x. Unger, H. W. (2016). Maternal Malaria and Malnutrition (M3) initiative, a pooled HIV, syphilis, malaria and anaemia in antenatal clinics in western birth cohort of 13 pregnancy studies in Africa and the Western Pacific. BMJ. : A longitudinal implementation study. PLOS ONE.

For more information Please contact the RBM Partnership to End Malaria at [email protected] or visit our website endmalaria.org.

Thematic brief produced in collaboration with